DECISION-MAKING IN HIV
HIV
STEP 1 Could it be HIV?
WHO TO TEST
www.testingportal.ashm.org.au/hiv
• Patients who request
testing
• Patients with another
STI or BBV
• People at risk (see below)
particularly if they have
had a flu like illness
• Pregnant women
• People diagnosed
with tuberculosis
• Patients with unexplained
immunosuppression
PEOPLE AT RISK
• Men who have sex
with men (MSM)
• Sexual partners of
HIV infected people
• People from a country
with high HIV prevalence
• Sexually active overseas
travellers
• People who share
injecting equipment
For further details on testing, see the National HIV Testing Policy 2011, available at www.testingportal.ashm.org.au/hiv
STEP 2 Informed consent and testing STEP 3 Conveying test results
BEFORE TESTING ORDER HIV Ag/Ab IF HIV POSITIVE
ASSESS RISK: ask about previous GIVE POSITIVE TEST RESULTS
‘Window Period’: is generally up to
history of testing, sexual, injecting IN PERSON
6 weeks (may be up to 12 weeks
and travel histories, testing for Listen and respond to patient needs
depending on the test used) from
other STIs an exposure and can give a false Avoid information overload
EVALUATE: patient’s general negative test result.
Check immediate plans, supports and
psychological state and social available services (e.g. www.napwa.org.au)
Initial positive HIV antibody or HIV
supports
antigen/antibody test results are Arrange other tests if appropriate
automatically sent to a reference (see monitoring) and arrange a
laboratory for confirmation. CONVEY specialist appointment
GAINING INFORMED CONSENT TEST RESULTS REFER
www.testingportal.ashm.org.au/hiv The laboratory will contact the Make a follow up appointment (GP)
(which should be within the next few
GP if initial tests are positive.
days) to review how the patient is coping
Discussion should be The pathologist will answer any
appropriate to the person’s questions at this stage and also Advise safe practices and condom use
gender, culture, language, advise if more blood needs to Contact tracing is the responsibility
behaviour and risk factors. be drawn. of the diagnosing doctor. If assistance
DISCUSS: the patient’s reason for Make arrangements for giving is needed, talk to the specialist service
testing, testing procedure, window results: check contact details about how best to proceed.
period, transmission, prevention are up to date. (http://contacttracing.ashm.org.au)
TALK ABOUT: confidentiality and
privacy issues around testing, IF HIV NEGATIVE
implications of positive and A NEGATIVE RESULT IS AN
negative test results
OPPORTUNITY FOR PREVENTIVE
CONVEY EDUCATION
RESULTS Recommendations for follow up
POST EXPOSURE PROPHYLAXIS (PEP) is the use of HIV antiretroviral medication testing can be discussed.
(ART) after possible exposure to HIV. PEP must be commence ASAP after exposure HIV transmission can be prevented by:
(within 72 hours) and taken daily for 28 days. • Using condoms during sexual contact
PRE EXPOSURE PROPHYLAXIS (PrEP) is the use of HIV antiretroviral medication (ART) • Avoiding contact with infected blood
before possible exposure to HIV. People with ongoing risk of HIV exposure can take (using clean injecting equipment)
daily ART to reduced possible infection. PEP and PrEP can be accessed through sexual • PrEP refer for discussion if at ongoing,
health clinics and specialised GPs. PEP can also be provided by emergency departments. high risk
• PEP
www.ashm.org.au
 DECISION-MAKING IN HIV
STEP 4 Further assessment and referral
Refer patient to a Sexual Health
Clinic, Specialist HIV unit or GP
with a special interest in HIV for
an initial assessment.
These services manage HIV-specific
care including antiretroviral therapy
(ART). The service will establish health
status through baseline blood tests.
These tests include those for immune
function, viral hepatitis and STIs.
GP should follow up to make sure
the patient attended the service
GPs can use Management Plans (GPMP),
Team Care Arrangements (TCA) and
Mental Health Plans for complex care
issues such as:
• Medical co-morbidity
• Depression and anxiety
• Drug and alcohol dependency
• Nutritional problems
Refer to psychologist, counsellors,
dieticians, peer support
(www.afao.org.au)
Additional copies and electronic version available at www.ashm.org.au/resources
Disclaimer: The Australian Department of Health provides financial assistance to ASHM, the material contained in this resource produced by ASHM should not be taken to represent
the views of The Australian Department of Health The content of this resource is the sole responsibility of ASHM.
STEP 5 HIV treatment by specialist services
All patients with HIV are advised to take antiretroviral
therapy (ART). ART is a combination of 3 medications
that suppress HIV replication. These medications are
generally co-formulated into 1-2 pills daily.
After starting ART, HIV viral load declines to a very low
level (‘undetectable’) usually < 20 viruses /mL after
REFER
a few weeks.
Suppression of HIV viral load allows immune recovery,
prevents complications and reduces HIV transmission
to partners.
Side effects are common at the start of treatment but
are usually manageable.
Immune function is monitored with 3-6 monthly
CD4 counts. CD4 recovers slowly following ART and
CONTINUE
TO HIV viral load suppression.
MONITOR CD4< 200 – severe immune suppression, may need
prophylaxis for pneumonia and other opportunistic
infections (OIs).
CD4 200 – 500 – moderate immune suppression
CD4 > 500 – normal
Regular liaison and communication between the GP
and specialist service about medication changes is
critical to patient safety.
CONTINUE CONTINUE
TO It is important for every patient to have a
MONITOR supportive GP for ongoing general health care MONITOR
FUNDED BY
The Australian
Department of Health
HIV
STEP 6 Monitoring
Monitoring may be performed by the GP or the specialist
service, arranged in consultation between the services and
the patient. A basic schedule is shown below. Individual
needs will vary. Extra monitoring is required for patients
starting or changing ART or for particular medications.
AT ALL VISITS: CHECK MOOD, GENERAL HEALTH,
ADHERENCE AND SIDE EFFECTS
MONITOR
Check for potential drug-drug interactions with prescribed and over
the counter (OTC) medications e.g. statins, proton pump inhibitors,
Viagra, inhaled steroids http://www.hiv-druginteractions.org/
THREE TO SIX MONTHLY REVIEW
• History and symptom review
• Weight, BP
• Investigations: FBC, LFT/UEC, CD4/CD8 count, HIV Viral load
• Syphilis serology and STI screen if ongoing risk
http://stipu.nsw.gov.au/stigma/sti-testing-guidelines-for-msm/
• Health promotion: prevent HIV transmission, smoking
cessation, review drug and alcohol use, healthy lifestyle
(diet and exercise)
ANNUAL REVIEW As above, plus
• Influenza vaccination
• Review vaccination status for hepatitis A (HAV)
and hepatitis B (HBV)
• Hepatitis C (HCV) testing if at risk
• Fasting cholesterol, HDL and LDL, triglycerides and glucose
TO • Annual cervical cytology in women
• Urinalysis (dipstick or protein/creatinine ratio)
• Cancer screening as per RACGP ‘Red Book’
www.ashm.org.au
© ASHM 2017. Published March 2017
ISBN: 978-1-920773-50-2